David N. Fisman

Prior Pneumococcal Vaccination Is Associated with Reduced Death, Complications, and Length of Stay among Hospitalized Adults with Community-Acquired Pneumonia

BACKGROUNDnVaccination with pneumococcal polysaccharide reduces the incidence of bacteremic pneumococcal disease in adults. We investigated the impact of prior pneumococcal vaccination on in-hospital mortality and the probability of respiratory failure among hospitalized adults with community-acquired pneumonia.nnnMETHODSnConsecutive individuals hospitalized with community-acquired pneumonia (diagnosed by International Classification of Diseases, Ninth Revision, Clinical Modification codes 480.0-487.0) at 109 community and teaching hospitals in the United States were identified using the Quality and Resource Management System, a database constructed by Tenet HealthCare to improve the quality of patient care. Vaccination status, comorbidities, and outcomes were abstracted by case managers concurrently with patient care. Associations between vaccination, survival, and respiratory failure were defined using multivariable logistic regression models.nnnRESULTSnOf 62,918 adults hospitalized with community-acquired pneumonia between 1999 and 2003, 7390 (12%) had a record of prior pneumococcal vaccination. Vaccine recipients were less likely to die of any cause during hospitalization than were individuals with no record of vaccination (adjusted odds ratio [OR], 0.50; 95% confidence interval [CI], 0.43-0.59), even after adjustment for the presence of comorbid illnesses, age, smoking, and influenza vaccination and under varying assumptions about missing vaccination data. Vaccination also lowered the risk of respiratory failure (adjusted OR, 0.67; 95% CI, 0.59-0.76) and other complications and reduced median length of stay by 2 days, compared with nonvaccination (P<.001).nnnCONCLUSIONSnPrior vaccination against pneumococcus is associated with improved survival, decreased chance of respiratory failure or other complications, and decreased length of stay among hospitalized patients with community-acquired pneumonia. These observations reinforce current efforts to improve compliance with existing pneumococcal vaccination recommendations for adults.

Projected Benefits of Active Surveillance for Vancomycin-Resistant Enterococci in Intensive Care Units

Hospitals use many strategies to control nosocomial transmission of vancomycin-resistant enterococci (VRE). Strategies include passive surveillance, with isolation of patients with known previous or current VRE colonization or infection, and active surveillance, which uses admission cultures, with subsequent isolation of patients who are found to be colonized with VRE. We created a mathematical model of VRE transmission in an intensive care unit (ICU) using data from an existing active surveillance program; we used the model to generate the estimated benefits associated with active surveillance. Simulations predicted that active surveillance in a 10-bed ICU would result in a 39% reduction in the annual incidence of VRE colonization when compared with no surveillance. Initial isolation of all patients, with withdrawal of isolation if the results of surveillance cultures are negative, was predicted to result in a 65% reduction. Passive surveillance was minimally effective. Using the best available data, active surveillance is projected to be effective for reducing VRE transmission in ICU settings.

Fatigue increases the risk of injury from sharp devices in medical trainees: results from a case-crossover study.

BACKGROUNDnExtreme fatigue in medical trainees likely compromises patient safety, but regulations that limit trainee work hours have been controversial. It is not known whether extreme fatigue compromises trainee safety in the healthcare workplace, but evidence of such a relationship would inform the current debate on trainee work practices. Our objective was to evaluate the relationship between fatigue and workplace injury risk among medical trainees and nontrainee healthcare workers.nnnDESIGNnCase-crossover study.nnnSETTINGnFive academic medical centers in the United States and Canada.nnnPARTICIPANTSnHealthcare workers reporting to employee healthcare clinics for evaluation of needlestick injuries and other injuries related to sharp instruments and devices (sharps injuries). Consenting workers completed a structured interview about work patterns, time at risk of injury, and frequency of fatigue.nnnRESULTSnOf 350 interviewed subjects, 109 (31%) were medical trainees. Trainees worked more hours per week (P<.001) and slept less the night before an injury (P<.001) than did other healthcare workers. Fatigue increased injury risk in the study population as a whole (incidence rate ratio [IRR], 1.40 [95% confidence interval {CI}, 1.03-1.90]), but this effect was limited to medical trainees (IRR, 2.94 [95% CI, 1.71-5.07]) and was absent for other healthcare workers (IRR, 0.97 [95% CI, 0.66-1.42]) (P=.001).Conclusions. Long work hours and sleep deprivation among medical trainees result in fatigue, which is associated with a 3-fold increase in the risk of sharps injury. Efforts to reduce trainee work hours may result in reduced risk of sharps-related injuries among this group.

Subthalamic nucleus deep brain stimulation for parkinson's disease after successful pallidotomy: Clinical and electrophysiological observations

Unilateral pallidotomy is an effective treatment for contralateral parkinsonism and dyskinesia, yet symptoms progress in many patients. Little is known about whether such patients obtain a useful response to subsequent bilateral subthalamic nucleus deep brain stimulation (STN DBS). Changes in Unified Parkinsons Disease Rating Scale (UPDRS) Motor and Activities of Daily Living (ADL) scores, medication requirements, and dyskinesias were measured. Clinical outcomes were compared to patients with de novo STN DBS. Neuronal recordings were performed. STN DBS resulted in a significant reduction in UPDRS Motor scores (42.1%; 95% confidence interval [CI], 26.9–57.4; P = 0.03), comparable with de novo STN DBS surgery (41%; 95% CI, 26–46%; P < 0.001). There was also less change in dyskinesia duration and disability scores (P = 0.017, 0.005). There were no side‐to‐side differences clinically or in the STN neuronal firing rates and patterns. Bilateral STN DBS is safe and efficacious in improving motor symptoms in patients with prior pallidotomy.

Acceptable rates of treatment failure in osteomyelitis involving the diabetic foot: a survey of infectious diseases consultants.

Shortening the duration of antibiotic therapy is an attractive strategy for delaying the emergence of antimicrobial resistance. The paucity of data about optimal treatment durations hinders adoption of this approach. This study used contingent valuation analysis to identify failure rates for treatment of diabetic foot osteomyelitis acceptable to infectious diseases consultants (IDCs). The Infectious Diseases Society of Americas Emerging Infections Network (EIN) provided members with the case scenario and 1 of 10 failure rates; members were asked, assuming delivery of standard therapy, if they would accept or reject the given failure rate. The relationship between specific failure rates and the willingness of IDCs to accept them was analyzed. The median acceptable failure rate for EIN members was 18.1%; 75% of IDCs found a failure rate of 7.8% to be acceptable, and 25% found a rate of 28.4% to be acceptable. The methodology used in this study may prove useful in delineating acceptable treatment failure thresholds, an initial step in shortening durations of antimicrobial therapy.

Physicians' acceptable treatment failure rates in antibiotic therapy for coagulase-negative staphylococcal catheter-associated bacteremia: Implications for reducing treatment duration

BACKGROUNDnDecreasing the duration of antimicrobial therapy is an attractive strategy for delaying the emergence of antimicrobial resistance. Limited data regarding optimal treatment durations for most clinical infections hinder the adoption of this approach and impair optimal physician-patient communication under the shared decision-making model. We aimed to identify acceptable failure rates among infectious disease consultants (IDCs) for treatment of central venous catheter-associated bacteremia.nnnMETHODSnA case scenario involving a representative patient who developed central venous catheter-associated bacteremia caused by coagulase-negative staphylococci and who received standard-of-care therapy was distributed to all nonpediatric IDC members of the Infectious Diseases Society of Americas Emerging Infections Network in August 2003. Each member was suggested 1 of 10 treatment failure rates and asked whether he or she would accept or reject the given value. Logistic regression was used to evaluate the relationship between specific failure rates offered to respondents and their willingness to accept them using a methodology derived from contingent valuation.nnnRESULTSnAmong the 374 respondents (response rate, 54%), the median acceptable failure rate was 6.8%. Thus, one-half of the IDCs would have found a failure rate of 6.8% to be acceptable. Seventy-five percent of IDCs would have found a failure rate of 1.6% to be acceptable, and 25% of IDCs would have found a failure rate as high as 11.9% to be acceptable.nnnCONCLUSIONSnThe quantified acceptable failure rates, when used to interpret clinical trial or cohort study results, will help select optimal antimicrobial therapy durations for this specific condition. These findings are a critical step in the development of effective shared decision-making models.

Using a Multi-Center, Computer-Based Surveillance System: Overcoming Data Collection Challenges with the Use of Technology and Creative Teamwork

Abstract ISSUE: Healthcare systems could benefit from a system-wide infection control surveillance database populated with data from component hospitals to assess the individual and collective effects of their infection programs. The challenge: obtain complete, accurate, and consistent data and, at the same time, not distract focus from prevention efforts. PROJECT: Tenet Healthcare, a system comprised of 113 hospitals, sought to develop an efficient data-collection and reporting system that provided outcome data in real time, allowed total hospital infection surveillance, and minimized manual data entry by using existing electronic hospital information systems. These data were automatically derived from the 1) admission, discharge, transfer database; 2) microbiology laboratory database; and 3) pharmacy database. Manual data entry was limited to case managers entering device use and device days and infection control practitioners (ICPs) identifying nosocomial infections. Accuracy of device data was assured by weekly assessment and cross-checking entered data with billing information and using CDC definitions to define nosocomial infections. Some hospitals assigned one individual to enter all device information to ensure complete data capture. ICPs met monthly to evaluate the system. RESULTS: Case Management, Infection Control, Nursing, and corporate managers collaborated to design an improved data collection system named eCARE (Electronic Clinical Analysis and Resource Efficiency). This program will be released by March 2004. New features include risk stratification, patient level “drill down” reports for all nosocomial infections, and comparative rate reports. LESSONS LEARNED: Focusing on three devices (central venous catheters, ventilators, and urinary catheters) made it easier to track device information. The inclusion of nursing management and directors of case management was crucial to successful denominator data collection, especially when measuring outside intensive care units. While hospital-wide data for internal benchmarking is helpful for identifying overall corporate rates, there is a need to stratify data by similar units to identify specific target areas for improvement. There is also a need to confidentially compare hospital-to-hospital data for external benchmarking.